O²C²S²

1. O²C²S² Changing payor, patient, and Provider perceptions

2. O²C²S² Identifying the problem: Spending more, getting less • $90 Billion was spent in the US in 1998 on direct costs for low back pain. Indirect costs are greater than direct costs.1 • Costs for back and neck problems increased 65% from 1997 to 2005.1 • Age- and sex-adjusted measures of mental health, physical functioning, work or school limitations were lower in 2005 than in 1997.2 1.Overview of Low Back Pain, McCarberg, Pain Medicine News Special Edition, Dec. 2010 2. JAMA Expenditure and Health Status Among Adults with Back and Neck Problems; Martin, Deyo, et al; JAMA, Feb. 13, 2008;Vol 299, No. 6

3. O²C²S² McCarberg, B, MD. 2010. Overview of Low Back Pain. Pain Medicine News, Dec. 2010. 8(12) pp 7-11.

4. O²C²S² US average rate of spine surgery per 1,000 Medicare enrollees Figure 1A. Trends in Overall Rates of Spine Surgery, 1992-2003

5. O²C²S² “Rates of back surgery in Casper, Wy., are 6 times those in Honolulu and the Bronx.” Neurosurgeons and Orthopedic Surgeons per 100,000 population Number of Back Surgeries per 1,000 Medicare Enrollees

6. O²C²S² Relationship between rates of spine surgery in 1992-93 and 2002-03

7. O²C²S² Spine Surgery per 1,000 Medicare enrollees (2002-2003) Each point represents the rate in one of the 306 HHR’s in the United States HHR = Hospital Referral Region

8. O²C²S² Why We Called Dartmouth USA TODAY ARTICLE OCTOBER, 2006 DON’T COMPLAIN OF BACK PAIN IN CASPER, WYOMING

9. Excerpts from USA Today Article For example, researchers found spinal surgery rates in 2002-2003 were almost eight times higher in some parts of the country, including Casper, WY; and Mason City, IA, than the lowest-surgery areas, such as the Bronx, NY; Honolulu, HI; East Long Island, NY; and South bend, IN Health care experts say spine surgery is just one example of how a complex set of conditions, which include expensive new technology, varying doctor preferences, financial incentives, patient expectations and a lack of data on what works best, is helping drive demand for medical care and raising costs.

10. Excerpts from USA Today Article Lower back pain is a condition that eight out of 10 Americans will experience at some point. And the cost is measured in more than just pain: Medical treatment of back pain is estimated to cost $25 billion annually, according to Duke University researchers. Workers compensation costs and time lost from work add another $25 billion. A growing share of those costs are from surgery. While over-the-counter medication and physical therapy are usually the first line of treatment, surgery for back pain has been rising rapidly for years.

11. O²C²S² The high rate of back surgeries in Bend Why there are so many spine surgeries locally remains elusive By Betsy Q. Cliff/The Bulletin Bendbulletin.com Published June, 18, 2009 4:00 a.m. PST Oregon has long been a darling of those who look at health costs. In most measures, the state including Central Oregon, shows remarkable restraint, turning in some of the lowest costs in the region. Against that backdrop, one number sticks out: the rate of back surgeries in Bend. For more than a decade, this area has had one of the highest rates of back surgery in the country. According to the latest data, from 2005, we have the second highest rate in the nation. Only Casper, WY, does more.

12. O²C²S² While back injuries are a significant issue world-wide, the state of Wyoming’s outcomes for work-related spine injuries are significantly lower than other states. Wyoming is one of 5 states that has an “F” in its return to work outcomes

13. O²C²S² Cost of Wyoming Workers Compensation Back Claims in 2009 Over $191 million in direct costs Over $21.5 million in new back claims $73.6 million spent on long-term back claims > 5 years Data provided by WSCD

14. O²C²S² “A study of more than 700 physicians indicated that only 25% followed guidelines for acute back pain without sciatica and 4.3% adhered to evidence-based recommendations when sciatica was present” (Webster, 2005). Webster, BS, Courtney, TK, Huang, YH, Matz, S, Christiani, DC. Physicians’ initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica. J Gen Intern Med., 2005: 20(12):1132-1135

15. Plan for Action O²C²S² Under the direction of Senator Charles Scott, Chairman of The Labor, Health, and Social Services Committee, the 2010 legislative session mandated Wyoming Workers’ Safety and Compensation Division (WSCD) conduct a trial on alternative approaches to treat spine injuries with the primary focus of reducing expenditures while improving outcomes.

16. O²C²S² In response to a request for proposal 501-T, WSCD Spine Injury Treatment Trial Program was awarded to the Wyoming Neuroscience & Spine Institute (WNSI) in August, 2010.

17. O²C²S² WNSI and Wyoming Workers Safety and Compensation Division, (WSCD) have entered into a contractual agreement as a one-year collaborative effort between a state agency, regional hospitals, physician specialty and primary care practices to improve the quality of care for patients who have sustained neck and back injuries while at work.

18. O²C²S² Optimizing Outcomes and Containing Costs for Spine Services: A trial Program NO. 0501-T O²C²S²

19. Through Many, Great Things Can Be Achieved • Wyoming Neuroscience and Spine Institute, (WNSI) • Wyoming Medical Center • Medical Director-Dr. Karen C. Nelson • Wyoming Brain & Spine Associates • Dr. Jay Ogsbury, Dr. Byron Jones, Dr. Joel Cohen, PhD, Psychology; • Kathy Blair, PhD, PT, Deanne Sramek, DNP, APRN, BC FNP; Stacey Zeidler; David Roberts, MS, MPH • Western Medical Associates; Rocky Mountain Family Medicine; • Casper Medical Imaging; Converse County Primary Care Group; • Salvus Solutions; Wyoming Health Medical Group; Sage Medical Group; Converse County Emergency Department; Central Wyoming Therapies; Wyoming Safety and Worker’s Compensation Division • - Over 90 professionals will be involved with this project

20. O²C²S² Background: Karen C. Nelson, PT, MS, MD • 8 Years of Musculoskeletal Physical Therapy • Masters Degree in Biomechanics • Medical school followed by 4 years in Physical Medicine and Rehabilitation Residency, and one year in Department of Anesthesiology for Pain Medicine Fellowship • Experience in workers compensation in 4 states • Immediately prior to joining WMC, practice in ninth-lowest medical service user among 404 US geographic areas. Grand Junction, Colorado spends 24% lower than the national average per capita on Health care per Dartmouth Atlas data.3 Low-Cost Lessons from Grand Junction, Colorado;Bodenheimer and West; NEJM; Sept. 30, 2010;1008450

21. Defining O²C²S² • O²C²S²is an integrated clinical practice model of health care delivery which implements a novel approach to spinal evaluation and treatment. • The goal of O²C²S²is to establish informed patients who are active participants in the decision-making, treatment, and functional rehabilitation process following injury.

22. Application of O²C²S² • Create a non-interrupted tracking process from the date of injury to maximal medical improvement and return to work using a designated clinical specialist who will facilitate compliance with guidelines as patients transition across medical disciplines.

23. Application of O²C²S² • Implement protocols for evaluation and treatment which will follow evidence based research, utilizing best practice guidelines specific for the nature and acuity of the injury and experienced resultant pain.

24. Application of O²C²S² • Key components include integration of assessment approaches and treatment methodology across medical disciplines who will utilize consistency in diagnosis nomenclature, correlating objective findings during clinical examinations and diagnostic studies.

25. O²C²S² • Education will be an integral part of O²C²S² pilot program.

26. O²C²S² Choices for Evaluations NoninvasiveInvasive -Physiatry -Injections -Physical Therapy -Discography -Chiropractic -Myelography -Medical Psychology

27. O²C²S² Patient Choices for Treatment • NoninvasiveInvasive • -Physical Therapy -Injections • -Chiropractic - Surgery • -Home Exercises • -Medical Psychology

28. O²C²S² • Assigning a case coordinator to each subject who will track the subject from date of injury to discharge through the protocols and facilitate communications and record keeping across medical disciplines • Designation from WSCD of a full-time case manager dedicated to 100 enrollees for the 12 month pilot program. • Establish open, regular, and documented communications in the form of multidisciplinary meetings with providers involved in the patient’s evaluation and treatment plan

29. O²C²S² • Upon completion of one year the data will be compiled and statistically analyzed for quality of care, return to work rates, conversion rates to chronic pain, as well as multiple other outcomes markers. • Insurance,(payors), health care providers, Employers and employees contribution to transition from the status quo of spending more with worse outcomes to O²C²S² will also be reviewed.

30. O²C²S² • The spine trial program is being offered to the injured worker as an alternative to incorporate spine treatment with both conservative and surgical options. • It is voluntary; injured worker’s can still elect to be seen by any health care provider they wish and can opt out of the program at any time.

31. Employer Process: Instruct injured workers with a work-related spine injury as follows: • After the injury is reported, the injured worker goes to seek medical treatment; • The injured worker must attend all scheduled appointments for spine evaluation • Wyoming Neuroscience and Spine will notify Worker’s Safety and Compensation of the injured worker who is enrolled in the clinical trial • Worker’s Compensation will coordinate the Employer and Employee incentives

32. INCENTIVE PROGRAMS • Employers in Converse and Natrona Counties may allow any injured worker with a work-related spine injury to elect to participate in the spine treatment trial program • Employers will receive an incentive by having expenses non-chargeable for each injured worker while participating in the trial program. • Patients selected through a randomization process may receive financial incentive for completing the study. The Health Care Provider must document the injured worker complied with the trial program and reached MMI Status for the incentive check.

33. Who will benefit from this program? • Patients/Injured Workers and their families • Wyoming Department of Worker’s Safety and Compensation • Employers • Providers • Payors

34. How will they benefit from this program? Patients/Injured workers • Patient’s will be playing an active role in their treatment plans • They will receive educational materials regarding their injury throughout the process • Minimal interruption from normal life activities allowing the patient to return to the same quality of life they knew before the injury • 80% of Patients return to work within 6 weeks of treatment • Potential financial incentive for the patients who complete the study

35. What will the patient’s gain through this process? • Regular Communication with staff will direct specifics of care as guided through treatment algorithms. • We will implement the biopsychosocial model requiring each patient to become an active participant in a shared decision making process. • Ongoing education will be provided to the patients, as evaluation and treatment plans are unfolded. • The emphasis of treatment will be function rehabilitation, de-emphasizing the role of surgery.

36. How will they benefit from this program? Wyoming Department of Worker’s Safety and Compensation • Millions of dollars in savings to the State of Wyoming • Development of an evidence-based treatment approach for Spine injuries

37. How will they benefit from this program? • 80% of injured worker’s return to work within 6 weeks from injury • Increased productivity • Cost savings on their Worker’s Compensation rates for those individuals participating in the study (expenses will be non-chargeable) • The long term residual effect will be Employer’s Worker’s Compensation Rates going down Employers

38. How will they benefit from this program? Providers • Guidelines • Using Evidence-based spine care for Patients • Literature Review • Wyoming Worker’s Compensation Division will send the participating clinic an incentive for each patient referral in to the program

39. O²C²S² Anticipated Outcomes • Demonstrate improvement in back pain treatment outcomes through patient activation and development of a collaborative multidisciplinary approach. • Improve State of Wyoming Workers’ Comp return to work rates • Standardize treatment pathways across the state of Wyoming according to current evidence-based recommendations. • Develop and make available educational material to patients, providers, state agencies, and insurers. • Improve appropriateness of surgical patients referred to surgeons creating efficiencies in their individual practices and improved surgical outcomes. • Lower the cost of care for Wyoming Workers’ Comp back pain program

40. O²C²S² Anticipated Outcomes • Reduce the number of inappropriate back surgeries to levels at or below the national norm as reported by The Dartmouth Atlas Report • Demonstrate quality outcomes to present to third party payers and negotiate preferred provider contracting • National Publication of the study results • Expand the model of care across other product lines • Accountable Care Organizations?

41. Questions or more information: • www.wyomingneurospine.com • Dr. Karen Nelson, Program Director, OOCCSS: painassociates@hotmail.com • Mark Smith, Program Coordinator OOCCSS, Director of Wyoming Neuroscience and Spine Institute: msmith@wyomingmedicalcenter.org • Stacey Zeidler, Care Coordinator OOCCSS: 307-235-2225 or szeidler@wmcnet.org